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Cervical cord exostosis compressing the axis in a boy with hereditary multiple exostoses

Case illustration

Marcus C. Korinth, Vincent T. Ramaekers, and Veit Rohde

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Paraplegia after contrast media application: a transient or devastating rare complication? Case report

Dorothee Mielke, Kai Kallenberg, Marius Hartmann, and Veit Rohde

The authors report the case of a 76-year-old man with a spinal dural arteriovenous fistula. The patient suffered from sudden repeated reversible paraplegia after spinal digital subtraction angiography as well as CT angiography. Neurotoxicity of contrast media (CM) is the most probable cause for this repeated short-lasting paraplegia.

Intolerance to toxicity of CM to the vulnerable spinal cord is rare, and probably depends on the individual patient. This phenomenon is transient and can occur after both intraarterial and intravenous CM application.

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Inadvertent intrathecal vincristine administration: a neurosurgical emergency

Case report

Maher Qweider, Joachim M. Gilsbach, and Veit Rohde

✓ Vincristine has a high neurotoxicity level. If given intrathecally by accident, it can cause ascending radiculomyeloencephalopathy, which is almost always fatal. The authors report a rare case in which vincristine was accidentally injected intrathecally into a 32-year-old man. The patient, who had Burkitt lymphoma, was neurologically intact, and it is likely that his survival was made possible due to aggressive neurosurgical therapy. After immediate cerebrospinal fluid (CSF) aspiration, external ventricular and lumbar drains were placed for CSF irrigation, which was continued for 6 days. This CSF irrigation was combined with 1) the intrathecal administration of fresh-frozen plasma to bind the vincristine and 2) an intravenous antineurotoxic therapy involving pyridoxine, folic acid, and glutamic acid. The patient's first sensorimotor deficits occurred after 2 days, led to an incomplete sensorimotor dysfunction below T-9 within the next 17 days, but progressed no further. Supported by the scarce data culled from the reviewed literature, the authors hypothesize that prolonged CSF irrigation combined with antineurotoxic therapy contributed to the patient's satisfactory outcome. In conclusion, accidental intrathecal vincristine injection requires emergency and adequate neurosurgical therapy.

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Functional outcome after surgical treatment of spontaneous and nonspontaneous spinal subdural hematomas

Ruth Thiex, Armin Thron, Joachim M. Gilsbach, and Veit Rohde

Object. Because of the rarity of spinal subdural hematomas (SDHs), the literature offers scarce estimates of the outcome and predictive factors in patients suffering from these lesions. In addition, single-institution surgical series are still lacking. Therefore, the authors retrospectively evaluated the early and long-term functional outcomes measured in eight patients with spontaneous and nonspontaneous spinal SDHs in whom the clot had been evacuated.

Methods. The patients' charts were evaluated for origin of the lesion, risk factors, and neurological deficits at symptom onset and at 28 days after extirpation of the spinal SDH. Long-term clinical outcome (Barthel Index [BI]) was evaluated by administering a telephone questionnaire to the patient or a relative.

Only one patient with a spontaneous spinal SDH was identified. Four patients were undergoing anticoagulant therapy, and three patients had undergone a previous anesthetic/diagnostic spinal procedure. Twenty-eight days postoperatively, neurological deficits improved in six of eight patients; however, in two of the six patients, the improvement did not allow the patients to become independent again. In two patients, surgery did not affect the complete sensorimotor deficits. In the long-term survivors (median 45 months) a median BI of 55 was achieved. The latency between symptom onset and surgery did not correlate with functional outcome in this series. The preoperative neurological condition and location of the hematoma correlated positively with early and long-term functional outcome.

Conclusions. To the best of their knowledge, the present study is the largest single-institutional study of patients with surgically treated spinal SDHs. Despite some postoperative improvement of sensorimotor deficits in most patients, the prognosis is poor because 50% of the patients remain dependent. Their outcome was determined by the preoperative sensorimotor function and spinal level of the spinal SDH.

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Editorial: Vasospasm

Nicholas C. Bambakidis and Warren R. Selman

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Early surgery of multiple versus single aneurysms after subarachnoid hemorrhage: an increased risk for cerebral vasospasm?

Clinical article

Dorothee Wachter, Ilonka Kreitschmann-Andermahr, Joachim Michael Gilsbach, and Veit Rohde

Object

As many as 33% of patients suffering from subarachnoid hemorrhage (SAH) present with multiple intracranial aneurysms (MIAs). It is believed that aneurysm surgery has the potential to increase the risk of cerebral vasospasm due to surgical manipulations of the parent vessels and brain tissue. Consequently, 1-stage surgery of MIAs, which usually takes longer and requires more manipulation, could even further increase the risk of vasospasm. The aim of this study is to define the correlation between vasospasm and the operative treatment of single intracranial aneurysms versus MIAs in a 1-stage operation.

Methods

The authors analyzed a database including 1016 patients with SAH, identified retrospectively between 1989 and 1996 and prospectively collected between 1997 and 2004. Exclusion criteria were endovascular treatment, surgery after SAH Day 3, and, in patients with MIAs, undergoing more than 1 operation. Cerebral vasospasm was diagnosed by transcranial Doppler (TCD) ultrasonography and was defined as a maximum mean blood flow velocity > 120 cm/second. The diagnosis of symptomatic vasospasm was made if a new neurological deficit occurred that could not be explained by concomitant complications.

Results

A total of 643 patients who experienced 810 aneurysms were included. Four hundred twenty-four patients were female (65.9%) and 219 were male (34.1%) with an average age of 53.1 years. One hundred twenty-one patients (18.8%) were diagnosed with MIAs. Maximum mean flow velocities measured by TCD were 131 cm/second in patients with MIAs and 129.5 cm/second in patients with single intracranial aneurysms. The incidence of TCD vasospasm (p = 0.561) as well as of symptomatic vasospasm (p = 0.241) was not significantly different in the 2 groups.

Conclusions

Clipping of more than 1 aneurysm in a 1-stage operation within 72 hours after SAH can be performed without increasing the risk of cerebral (TCD) vasospasm and symptomatic vasospasm.

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First experiences with an adjustable gravitational valve in childhood hydrocephalus

Clinical article

Veit Rohde, Ernst-Johannes Haberl, Hans Ludwig, and Ulrich-W. Thomale

Object

The goal of this report was to describe the authors' initial experiences with an adjustable gravity-assisted valve (GAV) called the ProGAV in treating childhood hydrocephalus.

Methods

The ProGAV was implanted in 53 children (29 boys and 24 girls, median age 7.3 years) with hydrocephalus of various origins. The ProGAV consists of a differential-pressure unit with adjustable opening pressures and a gravitational unit with a fixed opening pressure.

Results

The mean follow-up period was 15.2 months (range 6–44 months). The authors did not observe any valve-related complications. Four infections (7.5%) occurred, warranting the removal of the shunt. In 19 children, the opening pressure was changed at least once during the follow-up period, for underdrainage in 10, overdrainage in 8, and shunt weaning in 1, with substantial clinical improvement in 18 children. Overall, good clinical results were obtained in 47 (88.7%) of the 53 valve placements.

Conclusions

With an overall success rate of 88.7%, the first experiences with the ProGAV in childhood hydrocephalus are promising and justify its further use in the pediatric population.

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Fibrinolysis therapy achieved with tissue plasminogen activator and aspiration of the liquefied clot after experimental intracerebral hemorrhage: rapid reduction in hematoma volume but intensification of delayed edema formation

Veit Rohde, Ina Rohde, Ruth Thiex, Azize Ince, Axel Jung, Gregor Dückers, Klaus Gröschel, Carina Röttger, Wilhelm Küker, Harald D. Müller, and Joachim M. Gilsbach

Object. Fibrinolysis therapy accomplished using tissue plasminogen activator (tPA) and aspiration is considered to be a viable alternative to microsurgery and medical therapy for the treatment of deep-seated spontaneous intracerebral hematomas (SICHs). Tissue plasminogen activator is a mediator of thrombin- and ischemia-related delayed edema. Because both thrombin release and ischemia occur after SICH, the authors planned to investigate the effect of fibrinolytic therapy on hematoma and delayed edema volume.

Methods. A spherical hematoma was created in the frontal white matter of 18 pigs. In the tPA-treated group (nine pigs), a mean of 1.55 ml tPA was injected into the clot and the resulting liquefied blood was aspirated. Magnetic resonance (MR) imaging was performed on Days 0 (after surgery), 4, and 10, and the volumes of hematoma and edema were determined. In the animals not treated with tPA (untreated group; nine pigs), the volume of hematoma dropped from 1.43 ± 0.42 ml on Day 0 to 0.85 ± 0.28 ml on Day 10. In the tPA-treated group, the volume of hematoma was reduced from 1.51 ± 0.28 ml on Day 0 to 0.52 ± 0.39 ml on Day 10. In comparison with the untreated group, the reduction in hematoma volume was significantly accelerated (p = 0.02). In the untreated group, perihematomal edema increased from 0.32 ± 0.61 ml to 1.73 ± 0.73 ml on Day 4, before dropping to 1.17 ± 0.92 ml on Day 10. In the tPA-treated group, the volume of the edema increased from 0.09 ± 0.21 ml on Day 0 to 1.93 ± 0.79 ml on Day 4, and further to 3.34 ± 3.21 ml on Day 10. The increase in edema volume was significantly more pronounced in the tPA-treated group (p = 0.04).

Conclusions. Despite a significantly accelerated reduction in hematoma volume, the development of delayed perifocal edema was intensified by fibrinolytic therapy, which is probably related to the function of tPA as a mediator of edema formation after thrombin release and ischemia. Further experimental and clinical investigations are required to establish the future role of fibrinolysis in the management of SICH.

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Management of hydrocephalus in infants by using shunts with adjustable valves

Martin R. Weinzierl, Veit Rohde, Joachim M. Gilsbach, and Marcus Korinth

Object

Previous reports suggest that the use of adjustable differential-pressure valves may improve shunt performance. The absence of a flow- or siphon-controlled mechanism, however, is a concern. The goal of this prospective study was to assess the efficacy of valve adjustments in preventing slitlike ventricles in children < 6 months old after the first shunt insertion.

Methods

A total of 15 infants < 6 months of age who were undergoing initial shunt placement were included. Imaging was performed preoperatively, at 14 days postoperatively, and every 4 weeks thereafter. Ventricle size was assessed using ultrasonography and MR imaging or cerebral CT scanning at 1 and 2 years postoperatively. Clinical follow-up duration was 24 months for all patients. Valve settings were changed by 50 mm H2O if ventricle size decreased by 30% compared to preoperative size.

Results

The valve pressure setting was increased to 200 mm H2O in 11 children within the follow-up time, whereas ventricle size decreased from 0.6 ± 0.08 to 0.39 ± 0.09 (frontal/occipital horn ratio, mean ± standard deviation). There was neither clinical nor radiological evidence of underdrainage.

Conclusions

The adjustable differential-pressure valve used in this study was not effective in preventing slitlike ventricles in the majority of patients. Despite the small number of patients, this study provides a rationale for examining whether new shunt designs (gravitational shunt valves) are superior to conventional shunt systems in managing challenging hydrocephalus problems.

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Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery

Granit Molliqaj, Bawarjan Schatlo, Awad Alaid, Volodymyr Solomiichuk, Veit Rohde, Karl Schaller, and Enrico Tessitore

OBJECTIVE

The quest to improve the safety and accuracy and decrease the invasiveness of pedicle screw placement in spine surgery has led to a markedly increased interest in robotic technology. The SpineAssist from Mazor is one of the most widely distributed robotic systems. The aim of this study was to compare the accuracy of robot-guided and conventional freehand fluoroscopy-guided pedicle screw placement in thoracolumbar surgery.

METHODS

This study is a retrospective series of 169 patients (83 women [49%]) who underwent placement of pedicle screw instrumentation from 2007 to 2015 in 2 reference centers. Pathological entities included degenerative disorders, tumors, and traumatic cases. In the robot-assisted cohort (98 patients, 439 screws), pedicle screws were inserted with robotic assistance. In the freehand fluoroscopy-guided cohort (71 patients, 441 screws), screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. Patients treated before 2009 were included in the fluoroscopy cohort, whereas those treated since mid-2009 (when the robot was acquired) were included in the robot cohort. Since then, the decision to operate using robotic assistance or conventional freehand technique has been based on surgeon preference and logistics. The accuracy of screw placement was assessed based on the Gertzbein-Robbins scale by a neuroradiologist blinded to treatment group. The radiological slice with the largest visible deviation from the pedicle was chosen for grading. A pedicle breach of 2 mm or less was deemed acceptable (Grades A and B) while deviations greater than 2 mm (Grades C, D, and E) were classified as misplacements.

RESULTS

In the robot-assisted cohort, a perfect trajectory (Grade A) was observed for 366 screws (83.4%). The remaining screws were Grades B (n = 44 [10%]), C (n = 15 [3.4%]), D (n = 8 [1.8%]), and E (n = 6 [1.4%]). In the fluoroscopy-guided group, a completely intrapedicular course graded as A was found in 76% (n = 335). The remaining screws were Grades B (n = 57 [12.9%]), C (n = 29 [6.6%]), D (n = 12 [2.7%]), and E (n = 8 [1.8%]). The proportion of non-misplaced screws (corresponding to Gertzbein-Robbins Grades A and B) was higher in the robot-assisted group (93.4%) than the freehand fluoroscopy group (88.9%) (p = 0.005).

CONCLUSIONS

The authors’ retrospective case review found that robot-guided pedicle screw placement is a safe, useful, and potentially more accurate alternative to the conventional freehand technique for the placement of thoracolumbar spinal instrumentation.